Right to choose referral
18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.
19. Mr A complains a GP at the Practice delayed processing and gave him wrong information about being able to make an autism right to choose referral in September 2024.
20. The Practice said although Mr A provided referral information he received from the ICB that he had the right to choose, the information it received directly from the ICB was not initially clear. It said clarifying this information took longer than expected.
21. The GMC guidance says in providing clinical care, doctors must refer a patient to another suitably qualified practitioner when this serves their needs.
22. The records show Mr A sent an e-consultation request in mid-September asking to exercise his right to choose for an autism assessment. One day later a GP responded to Mr A saying they were unsure if right to choose was an option, but they would check this and contact him again.
23. The GP told Mr A the referral was completed and sent to the agency he chose in late October. This was one month and six days after Mr A’s request was sent to the Practice.
24. Our GP adviser told us that unfortunately, there is a national problem with autism referrals causing very long waits for patients, and some referrals are rejected months or even years after being sent. Our adviser also told us autism referral pathways have changed, and a lot of referrals are being rejected. This means GPs need to identify the correct pathway to minimise the risk of rejection happening which, in this case, caused an unfortunate delay.
25. We acknowledge Mr A is unhappy with how long it took for the GP to refer him for an autism assessment, and this caused him frustration and delayed access to the service.
26. Based on the evidence we have seen, the GP considered Mr A’s right to choose request. When they were uncertain if it was available, they asked for advice to ensure they could refer him and then completed the referral. This was in line with GMC guidelines and limited the possibility of his referral being rejected at a later date.
27. We are happy to hear Mr A was able to exercise his right to choose. We hope he is reassured we have seen no indication to suggest anything went wrong with the referral process.
Delayed blood tests
28. Mr A complains a GP at the Practice delayed organising blood tests discussed during an appointment in late September 2024. He told us this caused him frustration and delayed his referral to specialist services.
29. The Practice said the GP had to check what blood tests Mr A needed to then organise them. The Practice also said there was a slight delay because the GP had to take time off for illness and then covered other work commitments for colleagues.
30. The GMC guidance says clinicians must promptly provide or arrange suitable advice, investigations, or treatment where necessary.
31. We have looked at the consultation notes from this appointment and there is no record saying the GP planned to complete blood tests. It is clear from Mr A’s contact to the Practice in October that he expected to receive a link to organise these.
32. When Mr A contacted the Practice in early October, the Practice explained to him that it could not arrange the tests in the absence of clear documentation from the GP. It placed his blood test query into the administration queue of the absent GP, but it did not tell him that a response would be delayed until the GP returned.
33. Mr A contacted the Practice again four days later asking for an update because this was holding up his referrals to other specialists. The Practice GP responded to Mr A the same week, sending him a message to organise blood tests. The GP also told Mr A it could take up to two weeks to get the blood test results.
34. It appears that the GP did not document their plan to arrange the blood tests before unexpectedly taking sick leave. We can see the Practice admin staff did not fully explain things to Mr A when he made enquiries. We understand why this has caused him frustration.
35. From first Mr A asking about blood tests to being sent the link to book them was approximately 13 days. We are sorry to hear of Mr R’s concern that this delayed referrals he was waiting for. We acknowledge this caused him some frustration.
36. Given the short time Mr A waited, we do not think this reaches the threshold for us to investigate. We cannot see this had a lasting clinical impact for Mr A. We are pleased to see the Practice did arrange the tests and that it has apologised for the confusion and delay here. We think this is enough to put things right here.
Blood tests/ultra-sound regularity
37. Mr A complains the Practice gave wrong information about how regularly blood tests and ultrasound scans should be undertaken.
38. The GMC guidance says doctors must provide a good standard of practice and care. If they assess or diagnose patients, they must promptly arrange suitable investigations where necessary.
39. Our adviser said the guidance on the frequency of blood tests and scans depends on the situation. In Mr A’s case, for a referral to a Long Covid Clinic or similar, an individual service will typically list a series of pre-referral tests required.
40. Our adviser said there is no guidance recommending that these are repeated. This is because the need to repeat tests is based on the results and the clinical progress judged by the clinician.
41. Mr A’s ultrasound scan was of the liver and from the records was seemingly arranged at his previous practice due to a raised liver enzyme. Mr A did not attend this scan and was seeking another referral.
42. Our adviser said it was not unreasonable to re-request the scan that was reportedly considered necessary by a previous doctor, but there is nothing to suggest repeat scans would be required thereafter.
43. The GP documented in the middle of November 2024, that the specialist letter from November 2023 confirmed that the rise in Mr A’s liver enzyme was mild. The letter says further investigation confirmed that the risk was low. No routine repeat scans were planned, and Mr A was discharged from the Hepatology clinic with a recommendation to monitor him every two or three years. Our adviser said this would mean to monitor Mr A’s liver function via blood tests.
44. In this situation, our adviser said a GP should only arrange a repeat scan if there was a specific reason to do so, such as an upturn in the blood levels.
45. We do not consider based on the above that the Practice gave Mr A the wrong information as to how regularly blood tests and ultrasound scans should be undertaken. This is based on clinical judgement and an indication in symptoms or results to complete the investigations, rather than being at set intervals.
46. We acknowledge Mr A’s concern and worry regarding this. We hope our explanation here has provided him some reassurance regarding the Practice’s action. As we have seen no indication something has gone wrong here, we will not consider this part of the complaint further.
Long COVID service
47. Mr A complains the Practice submitted an incorrect referral to the long COVID service between September and November 2024. He says this delayed his access to specialist care, which caused him stress, anxiety, and a loss of faith in the GP’s actions.
48. The Practice said when Mr A had a telephone appointment with a GP in September, they did not know there was a long COVID service to refer him to. The Practice said its GP made a referral for Mr A to the post COVID assessment clinic in early November and was waiting to hear if he had been accepted. The GP also considered services for Mr A such as chronic fatigue to find other ways to help him.
49. The GMC guidance says doctors must refer a patient to another practitioner when this serves the patient’s needs.
50. In late September, the GP and Mr A had a telephone appointment where he asked to be referred to a long COVID clinic. Mr A had previously been seen in a clinic in another area. The GP sent Mr A a message saying they believed the long COVID service was no longer available, but they would refer Mr A to another suitable specialist.
51. In November, the GP told Mr A they would refer him to rheumatology services but when Mr A shared information that a long COVID service was available, the GP referred him to that service. In late November, the Practice received a rejection notification from the long COVID service because it believed Mr A had not had the infection.
52. One day later, after seeing the rejection in his medical information, Mr A gave the Practice more information to support another application. The GP submitted it again in early December and made Mr A aware.
53. Our GP adviser told us as the GP was not aware there was an option to refer their patient to a long COVID clinic, the plan to establish the correct pathway before making the referral was reasonable.
54. The records show a five-week delay in the Practice completing the long COVID referral. This appeared to be largely due to the GP’s sick leave and helping cover other GP’s workloads. Our adviser said this would not have had a significant clinical impact on Mr A.
55. We acknowledge Mr A was frustrated and anxious due to the delay in his long COVID referral.
56. Based on what we have seen, the Practice considered what services were available and appropriate for Mr A. We recognise the delay would have caused Mr A frustration and anxiety for a short period of time while waiting. Given the relatively short time Mr A waited, and the lack of lasting impact, we do not think this reaches the threshold for us to investigate.
Sarcoma referral
57. Mr A complains the Practice made an error when referring him to the sarcoma service for bone lesion growth on his right elbow.
58. The sarcoma guidance says a person should be referred for a suspected bone sarcoma on a suspected cancer pathway referral for adults (28 days). Our adviser said in Mr A’s case it was not unreasonable to use the same approach as one would for a newly suspected cancer.
59. We can see from the records Mr A’s bone lesion had been picked up in 2018. He had been monitored by the Royal National Orthopaedic Hospital since it had been identified.
60. We can see from the records Mr A’s initial referral made by the Practice in October 2024 did not include which elbow was involved in the scan so was not completed. The hospital requested further information from the Practice in November 2024, and the GP responded in less than a week.
61. The Practice does appear to have made an error when referring Mr A to the sarcoma service by not including which elbow needed to be scanned. Given this, and the subsequent short delay rearranging another referral, we acknowledge this would have caused Mr A to experience some frustration.
62. Our adviser explained the short delay in Mr A being seen by the sarcoma service would not have impacted the clinical care he received. Most of the delay related to the request for additional information rather than that request being actioned.
63. We acknowledge this situation would have been a frustrating and stressful period for Mr A. We are pleased the Practice promptly rearranged his referral to the sarcoma service. Given the relatively short period of time Mr A waited to see the sarcoma service and his overall clinical care being unaffected, we do not think this reaches the threshold for us to investigate.
Progress updates and responses
64. Mr A says the Practice and GP did not communicate or give him updates between September and October 2024. He says this caused him anxiety and frustration asking for information.
65. GMC guidance says clinicians must give patients the information they want or need in a way they can understand.
66. Mr A asked the GP for referral updates about his autism and long COVID referral when the GP was absent from work. The Practice said its GP took time off and then covered other sick colleagues’ workloads, which resulted in Mr A experiencing a delay in his requests being answered and completed.
67. The Practice did not share this information with Mr A when he contacted them in early October. It recognised because of this Mr A experienced more frustration and anxiety than necessary.
68. The Practice said Mr A’s GP apologised in person in October for the delays caused when making his referrals and finding the correct information to support his care. It recognised Mr A should have been given updates.
69. We also acknowledge Mr A’s communication worries caused him to feel anxiety and concern about how the GP and Practice would handle any future health concerns he raised.
70. Our Principles for Remedy says organisations should promptly identify and acknowledge poor service and apologise for this. An apology means acknowledging the failure, accepting responsibility for it and expressing sincere regret.
71. The records show the GP provided Mr A with an apology and explanation about why communication with him did not take place as expected, with the GP explaining Mr A’s volume of queries had overwhelmed them. The Practice explained to Mr A there was shortfall in its administration service when it did not tell him there would be a delay receiving a reply to his referral questions, because the GP was not available to respond.
72. The Practice being open and honest about the error made and giving apologies are in line with our Principles for Remedy. Because of this we consider the Practice has acted in line with Our Principles, and has done enough to put things right here.
73. In summary, we have seen the Practice followed guidance when making Mr A’s referrals and organising tests. We are pleased to see there were no issues with the clinical care Mr A received at the Practice. We do recognise the frustration the short delays he experienced caused him. We hope Mr A is reassured the actions of the GP regarding his referrals and health were appropriately acted on.
74. We thank Mr A for bringing his complaint to us for consideration and we hope we have explained our decision why we will not consider his complaint further clearly.